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r Applications Will Be Processed When Submitted Properly Comple edF ell rIT���Si The Alli . <br /> FOR cffllCE USE: APPLICATION � <br /> _Ds <br /> (For Non-Transferable, Revocable, Sus ble) � aQ <br /> IA AR 1 PUMP& I. <br /> ENVIRONMENTAL HEALTH PERMIT TIZ,1, 11 <br /> WATER QUALITY SAS <br /> (COMPLETE IN TRIPLICATE) rTi�'° <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or(+� 2f1,1{ttl�iv of Wa i'h'i J cribed.This application is <br /> s made in compliance wit S�J Lim County rdi ance No.1862 and the rules and regulations of the Sari Joaquin Local Health District. <br /> Exact Site Address City/Town f� <br /> Phone � <br /> Owner's Name <br /> City 1k QzC <br /> Address <br /> Contractor's Name License# 10 Business Phone <br /> Contractor's Address l_ 12 2 7 Emergency Phone 6�- S <br /> Is Certificate of Workman's Compensation Insu ance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑., <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> t <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Fieldspool/Seepage Pit Other <br /> Property Line Private DOmestlC'QPell ��.. Public Domestic Well <br /> INTENDED USETYPE OF WELL <br /> 11INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ OMESTIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> lJ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed fay: r ' <br />- p <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. H.P. <br /> PUMP REPLACEMENT: State Work Done U °Q` 301 <br /> 1 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issue not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Co actor's hirin ar sub-cont cling s' ure certifies the following:"I certify that in the performance of the work for which this <br /> p mit is issued hall emp s ject to rkman's compensation laws of California." <br /> will cal out I a grou g and a final inspection. 01 <br /> f Signed X _ Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEP RTMENT USE ONLY <br /> PHASE I % 3 Q <br /> Date <br /> Application Accepted By— <br /> Additional <br /> y Additional Comments: <br /> Phase II Grout Inspection Phase Fina! Ins ate <br /> Inspection By n <br /> Date inspection B <br /> ,...,//_ <br /> Fee Is Due: ❑ ANNUALLY C1 PER UNIT rG PER SITE El EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BASE kEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DA DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i OTHER <br /> Received by Date Receipt No. Permit No. Issuan a Date Mailed Delivered <br /> k APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009- STOCKTON,CA 95201 <br />